Opioids Are Not a First-Line Treatment for Chronic Pain, Pain Specialist Says

When someone living with HIV complains about chronic pain, take their word for it, but try non-opioid therapies and treat underlying psychiatric illnesses before prescribing oxycodone, Jessica S. Merlin, M.D., M.B.A., advised health care providers in a recent webinar. People living with HIV are more likely to suffer from such pain (30%-85% report chronic pain) than the general population (15% report that issue). This may be partly due to greater sensitivity to pain in those with detectable viral loads, Merlin explained.

Providers must understand the impact that this condition has on a patient's daily life, screen for mood disorders and note the patient's coping strategies before suggesting a therapy approach, Merlin advised in the Chronic Pain in HIV Infection: A Practical, Evidence-Based Approach webinar sponsored by the International Antiviral Society-USA on August 18, 2016. An effective technique Merlin has used in her chronic pain clinic is motivational interviewing, which is designed to stimulate people's own motivation for change, rather than simply telling them that they should change their behavior. She counseled providers to educate patients about ways to control pain without resorting to prescription medications, including mind-body techniques and short-term, over-the-counter drugs, such as acetaminophen. The latter, however, has problematic side effects when taken long-term, especially in combination with antiretrovirals, Merlin cautioned. Other approaches include physical therapy and exercise, as well as topical medications.

Providers should develop a team either within their office or within the community; it should include mental health professionals, methadone programs and social workers, among others. Such a team approach allows for better screening and treatment of depression, PTSD and other conditions that may co-occur with chronic pain. These problems need to be addressed first to remove the underlying cause of the pain, rather than treating only the symptoms.

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Opioids should not be considered first-line therapy for chronic pain, Merlin emphasized. Evidence of their benefit is limited, and no studies have evaluated their use for longer than one year. By contrast, evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted, as well as a risk of overdose, especially when co-prescribed with benzodiazepines. Providers should take universal precautions when prescribing opioids, rather than deciding who is or is not at risk of opioid use disorder. These precautions include having the patient sign an opioid treatment agreement, with provisions for using only one prescriber and one pharmacy and submitting to frequent urine drug testing. However, urine tests can result in false positives, especially when someone takes multiple medications, as is the case with those living with HIV, Merlin noted. A confirmatory assay, as well as a conversation with the patient, are therefore necessary before jumping to conclusions.

If all non-opioid attempts at managing the chronic pain have failed and oxycodone or a similar drug is prescribed, the lowest effective dose should be used. Patients should be re-assessed at least every three months, other therapies should be optimized, and the opioid dosage prescribed should be tapered off over time with the goal of eventually discontinuing it altogether. Merlin also advocated co-prescribing naloxone for high-risk patients, if they can bring in someone who lives with them and can administer the antidote in case of opioid overdose. However, local laws differ as to whether this approach is permitted. Laws on marijuana use also differ among states, but where legal the substance may be useful in treating chronic pain. Evidence shows that people who are prescribed medical marijuana use opioids less, reducing the risks associated with opioids.

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